October #40 : Climb Every Mountain - by Richard Goldstein

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Table of Contents

Open Wide, AIDS Ride

Climb Every Mountain

The Necessity of Excess

The Latest on Early Intervention

Photo Copy

Tomorrow's "It" Girl

Post-Gay Poster Guy

S.O.S.

To the Editor

Bazaar Science

Drug Bust

News Ruse

Standard Issue

The New Reality

Say What

Life After HIV

Pot for Thought

Micro Softee

World Cup: Europe vs. US

Summer Camp

A Colder War



Most Popular Lessons

The HIV Life Cycle

Shingles

Herpes Simplex Virus

Syphilis & Neurosyphilis

Treatments for Opportunistic Infections (OIs)

What is AIDS & HIV?

Hepatitis & HIV


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October 1998

Climb Every Mountain

by Richard Goldstein

The art of selling HIV drugs

All advertising exists in a state of anticipation. Out there is something wonderful or profitable or sexual; purchase this product and possess it. Drive the car and embody its power, sip the drink and enter its erogenous zone, dab on the scent and keep the demons of decay away. Even detergents promise a brighter day, so what should we expect of ads for protease inhibitors? Pop this pill and coast on the foamy crest of health.

Of course, when it comes to treating HIV, the stakes are so high that they might call for something more candid than the usual hype. But it turns out that AIDS lends itself quite handily to the allure of advertising. Who has been more susceptible to the promise of a better tomorrow than PWAs, with their record of desperate faith in the epidemic's many Compound Qs? And precisely because the protease drugs offer tangible hope of substantially reducing viral load -- if not for everyone, if not permanently -- they can be pitched quite efficiently.

The first wave of these ads hit in 1996, just before the short-lived promise that the dream of "HIV eradication" was about to come true. As the standard of care changed from mono- to combo therapy, drug companies stoked the promotional fires in anticipation of a profit bonanza. Two years later, the dream has been scaled back to "remission," but the blaze of hype burns even more brightly. It's as if the more ambiguity that surrounds the performance of these drugs, the more eager pharmaceuticals are to represent them as agents of transformation.

Which is why ads for HIV drugs are not so different from commercials for those no-drowsiness allergy meds, such as Allegra, available only by prescription. Of course, the market for protease inhibitors is narrower, so we haven't yet seen any 60-second TV spots. What we do see -- not only in POZ and the gay, black and Latino press, but in subway and bus ads nationwide -- is an Allegra-style fantasy of health. Yet there's something even zanier about ads for HIV drugs. While Allegra merely promises sneeze-free days of blue skies and green fields, the pitch for protease inhibitors makes a far more ambitious offer. These drugs won't just make you feel better; if you believe the hype, they can change your life.

It may seem ironic that the noble and hard-won crusade to portray PWAs as vital, active citizens -- people living with AIDS -- should fold so easily into a strategy for plugging pharmaceutical products. But this process of stylization reflects a larger shift in the way the epidemic is perceived. No longer is the PWA seen as an activist working the system to wrest everything from funding to freedom. Now the PWA is just another consumer, one more niche in the morbidity-and-mortality market. This growing dependence on commodities rather than community matches the increasing reliance of AIDS activism on pharmaceutical companies. It's as if the entire epidemic -- from the soup of treatment to the nuts of politics -- is rapidly becoming commercialized. So no one should be surprised to see the once-militant image of the PWA evolve into that of the serenely confident Zerit man, the ubiquitous, all-inclusive icon who is certainly black but not necessarily gay. If his sexuality is ambiguous, though, the state of his health is not. Like the rest of the combo chorus, he shows no signs of side effects: no fever, nausea, headache, no liver or kidney problems, no high triglycerides, no protease paunch or puppet-face deformities.

The current crop of ads typically presents the positive consumer as a gold medal-caliber athlete, manning a sloop, climbing a mountain or hurling a javelin. Not that people with HIV can't do such things. (Indeed, a Viramune ad portrays the "HIV+ crew of the Survivor" sailing in a real regatta.) But reality is not the point. Just as Leni Reifenstahl used dynamic cinematic techniques to transform the 1936 Berlin Olympics into a metaphor for Nazi supremacy, these drug ads use physical proficiency to create an aura of personal mastery. We can't cure you, they seem to say, but we can keep you active -- and, perhaps more important, looking good.

To some extent, this is a plausible promise. (If it weren't, the Food and Drug Administration, or FDA, which regulates direct-to-consumer drug advertising, could prevent such claims from being made.) But it's hardly the whole story. Though the ads mention side effects, they give little sense of how deep the downside of these drugs can be. Only when you read the fine print that fills the "PI," or prescribing information, on the subsequent page, will you discover that the "contraindications" may be severe, even fatal.

"I know a lot of people taking these drugs who have experienced the Lazarus effect," says veteran ACT UP/New Yorker Eric Sawyer. "But I also know a lot of people who have had their hair fall out, and their skin color go from light brown to a really horrendous gray." Sawyer, whose six-combo regimen includes Viracept, is none too happy about its ads, part of a new generation of HIV-drug promos that show no people at all. While so-far-drugless Vertex swipes the rhetoric and graphic style of ACT UP to cast its product as part of the push for a cure, Agouron pitches Viracept with a cutie-and-the-beast approach, featuring a grizzly/teddy duo and the tag "Powerful and Easy to Live With." "If you've ever dealt with diarrhea," says Sawyer, "you know it's anything but easy to live with."

The Imodium chaser to a protease cocktail may be a small price to pay for the drugs' benefits. But since these ads offer an implicit endorsement of the early-intervention dogma, the very promise is a problem, according to Mark Harrington, policy director of Treatment Action Group. "These ads feed the perception that you should begin treatment immediately upon diagnosis, whereas we don't know when asymptomatics should start treatment." So Harrington isn't pleased by the shift from images of "happy end-stage people selling their life insurance" to HIVers going for the gold. "They don't reflect reality," he says. "The models are all buppies or yuppies having fun. It fits into the perception that this is a groovy disease, and if you get infected, it's not so bad. In a sense, these ads are insidious."

No more insidious, maybe, than a campaign for cigarettes featuring groovy people in a Newport moment. But, as Richard Isay, a psychotherapist who has worked with gay men for 20 years, notes, "I've never known someone to have unsafe sex after seeing a handsome man in an ad." Isay adds that there are deeper reasons why people have unsafe sex even in the face of getting infected. But surely, images of people with HIV as objects of power and desire resonate with the nearly universal sexual fantasies of risk and reward.

The ongoing debate over whether these ads subvert HIV prevention raises a larger issue: Is it more important to keep negative people safe or positive people healthy? Whose life should be at the center of our concern? But this issue, fraught as it is, begs the question of how glamorizing ads affects people facing the real consequences of treating HIV. How does it feel to falter on these drugs when ads say you should be scaling the heights?

Bob Hattoy, a presidential adviser on HIV since Clinton's 1992 election, was appalled to see drug-company booths at the World AIDS Conference in Geneva so lavishly high-tech that they looked more like displays at an electronics consumer show. So he approached a Merck booth staffer, and with images of the company's robust Crixivan adventurer fresh in his mind, Hattoy quipped, "I'm doing pretty well on your drugs, but when am I going to look like a mountain climber?" The Merck rep was unperturbed. "Do you have a question?" he asked before turning away.

"Of course, they're not going to show us puking and farting," Hattoy says. "But almost everyone I know has had some kind of side effect from these drugs. And when that happens, the ads make you think you're doing something wrong. It's performance anxiety. You feel like you can't compete."

Performance anxiety is nothing new in this promo-saturated environment. We live with it every time we turn on the tube or check out the impossible bodies in a fashion spread. The basic repertoire of advertising has become a fixture of the unconscious, right up there with the libido. But you'd think the actual prospect of death would change the fantasy. On the contrary. What advertisers have discovered is that people with HIV -- at least in focus groups -- prefer to associate their drugs with feats of daring.

"Our campaign was created by talking to people with HIV and understanding their feelings about being positive," says Howard Buford, president of Prime Access, the agency that devised the Crixivan ad. "People with HIV were saying it feels like a battle against nature. So we explored different ways of communicating that, and the one that people responded to was rock climbing. It conveyed the image of endurance, and this is a very durable drug."

Hence, the saga of the Crixivan ascent. Like many successful ad campaigns, this one evolved over time from adversity to triumph. It began in 1996 with a climber staring at the rock face before him. "He's in the middle of a struggle," says Buford. Subsequent ads showed the same climber helped to the summit by a hunky black man. And then he's on top, standing with a proud black woman against a pure blue sky. (Never mind the shifting cast of characters -- this is an equal-opportunity fantasy.) "They don't have their hands in the air," says Buford. "We didn't want to communicate that science has found a cure." Instead, the copy reads, "If you're HIV+ Crixivan may help you live a longer, healthier life." A plausible message, but it pales before the deeper meaning of the quest. You're clawing to stay alive, the imagery suggests, but with this drug you can stand at the summit, looking down.

Of course, the federal government doesn't regulate fantasies (at least of the promotional kind). But drug companies are required to submit ads for prescription-only products to the FDA. Approval is granted as long as the ads seem "accurate and balanced," says FDA spokesperson Brad Stone. "By that we mean that the information provided has to be about not only the potential benefits but also the potential problems." For print ads, this entails a separate section offering what the FDA calls "brief summary information" about the product. The larger type that accompanies all that life-affirming imagery typically downplays the gravity of side effects. To find the word death, for example, you have to get out a magnifying glass.

This pyramiding of information -- with the best news first, in the largest type, and the worst only as an after-thought -- is what leads Harrington, a longtime proponent of streamlining the drug-approval process, to argue that ads for HIV drugs need to be more stringently regulated. In fact, a source familiar with the approval process says that the FDA asks HIV drug companies to rewrite ads all the time. That's why you won't see either the appetite-stimulant Marinol, which contains synthetic THC (the active ingredient in marijuana), represented in a party setting, or gay guys with testosterone-patches at a tea dance, since this product is prescribed for hormone deficiency, not to promote horniness. "There have been instances when manufacturers have asked for our comments and we have asked for changes," says Nancy Ostrove, the FDA's branch chief of marketing practices and communication. But she declined to be more specific, calling that "proprietary information." Yet when informed of ads that mention fatal side effects only in the fine print, Ostrove asked to see copies. "The surveillance of that class of drugs is shared among a number of people," she says, "so it's possible that there are ads we haven't seen."

If certain PWAs had their way, what might an alternative ad campaign for HIV drugs look like? No one expects to see people in the throes of side effects -- that wouldn't be advertising. But Harrington says that ads at least ought to show people caring for each other, while Hattoy opts for another kind of realism: "It's enough to get to work and have a decent social life." But for Mario Cooper, a leading AIDS activist in the black community, the most important thing is to combine promotion and prevention. "The paradigm must change," says Cooper. "We need a new strategy of communicating, one that involves neighborhoods and traditional organizations." One image Cooper would like to see is a PWA singing in a church choir.

But the focus groups would prefer a buff black man on a bicycle, as in the Zerit ads. "We've tested our ads on black and Latino people, and the communication is very strong," says Buford, whose Prime Access agency specializes in marketing to black, Latino and gay communities. "It's condescending to think that black people can't get it unless it's in their face."

In the end, all advertising is symbolic, whether we get it or not. If we aren't being warned about the danger of living without a product, we're being tempted to meet impossible expectations. As Americans, we're taught that we can never have enough love, money or power, and that commodities can fill the gap between reality and our restless dreams. Health is no exception. Is it any wonder, then, that people with HIV respond so viscerally to ads that promise an infinitely buff, eternally active body, one with no sign of disease? This is the status quo in a culture where a sleek surface is a sign of grace.

So perhaps the most dramatic effect of HIV drug ads is not to make PWAs seem glamorous, but to make them seem normal, one more consumer group in the endless segmentation strategy of mass marketing. For someone living with HIV, this may be the most powerful promise of all. Maybe it's not the search for perfection that makes the climb-every-mountain fantasy so compelling. Maybe what it signifies is the illusion all advertising promotes: that a product can make us normal by "managing" the disease that is ordinary life.




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